Pediatric Examination and Board Review (129 page)

(A) abortions after 16 weeks of gestation carry a risk for complications 15 times higher than those performed before 12 weeks

(B) abortions done between 9 and 12 weeks of gestation have a tenth of the complication rate of carrying the pregnancy to term

(C) teenagers are less likely to have a second trimester abortion than older women

(D) adolescents younger than 19 account for 20% of all legal abortions

(E) 41% of teen pregnancies end in abortion

12.
During the private interview with the patient, she admits to drinking “socially” on weekends, sometimes to drunkenness, and to smoking marijuana 3 times a week. All of the following statements regarding alcohol use are true except

(A) no amount of alcohol is safe in pregnancy and total abstinence is recommended

(B) the use of alcohol during pregnancy can lead to fetal alcohol syndrome or spontaneous abortion

(C) by age 15, 1 in 10 boys report they are problem drinkers

(D) 34% of American 12th graders report having been drunk in the previous month

(E) alcohol is involved in 40% of adolescent mortality resulting from MVAs

13.
Which among the following is not a physical consequence of acute heavy drinking?

(A) acute gastritis

(B) hyperthermia

(C) acute pancreatitis

(D) amnesia

(E) ataxia

14.
Concerning marijuana use, all of the following statements are true except

(A) cigarette smoking is more common than marijuana use in teens

(B) up to 48% of high school graduates have used marijuana at least once

(C) marijuana can be detected in the urine for up to 30 days after single-time use

(D) the duration of action of marijuana is 3 hours if smoked

(E) the typical potency of street marijuana is 4-6%

15.
All of the following symptoms and signs may be attributed to marijuana use except

(A) conjunctival hyperemia

(B) increased appetite

(C) mood fluctuations

(D) impaired learning and cognition

(E) nausea

16.
What percentage of 12th graders report ever having used an illicit drug?

(A) 3%

(B) 10%

(C) 25%

(D) 53%

(E) 66%

17.
What is the percentage of 12th graders who report ever having used an illicit drug other than marijuana?

(A) 3%

(B) 10%

(C) 33%

(D) 50%

(E) 60%

18.
Among the following, which is the most common drug of abuse (other than marijuana) used by eighth graders?

(A) smokeless tobacco

(B) amphetamines

(C) inhalants

(D) crack cocaine

(E) methylenedioxymethamphetamine (MDMA)

19.
The patient returned 2 days later with her grandmother. She stated that both she and her boyfriend had decided to seek a pregnancy termination. She had not told her family about the pregnancy yet and asks you to help her do so. Her grandmother was disheartened and upset after hearing the news, but in the end, she supports her granddaughter’s decision. The patient was seen by an obstetrician and underwent a suction curettage 2 days later, without complication. She comes to see you 2 weeks later for follow-up. All of the following should be done at this time except

(A) ask about ongoing contraceptive methods

(B) ask about fever, pelvic pain, vaginal discharge, or continued bleeding

(C) perform a pelvic examination to confirm uterine involution and absence of tenderness

(D) check a urine pregnancy test

(E) start contraception

20.
The patient wants to start depomedroxyprogesterone acetate shots. Your advice about this method should include the following except

(A) depomedroxyprogesterone acetate is one of the most effective hormonal contraceptions available

(B) the most common side effects of depomedroxyprogesterone are irregular menstrual bleeding and weight gain

(C) depomedroxyprogesterone should not be given until a month after pregnancy termination

(D) osteoporosis may result from long-term use

(E) it is a good method for adolescents who have difficulties with medication compliance

ANSWERS

1.
(E)
A history of medication and substance use should be elicited from all adolescents, and a detailed sexual history is essential in all sexually active teens. This includes, among others, age at first intercourse, types of sexual contact, sexual orientation, type of contraceptive use, number of sexual partners, use of alcohol or other drugs associated with sexual activity, and past history of STDs.

2.
(E)
Because the differential diagnosis of abdominal pain is quite extensive, a comprehensive physical examination will be needed. The recent onset of sexual activity and frequent urination in an adolescent girl who has been an unreliable historian in the past point to the need for a pelvic examination even if her menses are reported as normal. The pelvic examination would help to rule out pregnancy and STD as a cause of her abdominal pain. Given the history of possible marijuana use, one should look for signs of acute or chronic intoxication. For example, in acute intoxication, conjunctival hyperemia, and an abnormal neurologic examination with decreased coordination, sleepiness, slow reaction times, decreased postural stability, increased body sway, and dilated pupils are characteristic. Tachycardia may be present and orthostatic hypotension may develop at larger doses. Clinical signs suggestive of other substance use should be explored.

3.
(B)
In the absence of any clinical sign of abnormal early pregnancy, it is likely that the reported date of the last menstrual period was inaccurate. A uterus that is palpable in the abdomen just at or above the symphysis pubis signifies a pregnancy of approximately 12 weeks. The uterine fundus reaches the navel at 20 weeks and the rib cage at 40 weeks.

4.
(E)
Any of the above could explain the finding of a uterus larger than expected for dates.

5.
(D)
In ectopic pregnancy, incomplete or missed abortion, and hCG-secreting tumors (a very uncommon occurrence), the uterus is smaller than expected for dates. However, in the presence of a corpus luteum cyst of pregnancy the uterus may seem to be larger than expected for gestational age.

6.
(E)
A transvaginal pelvic ultrasound will help determine fetal size and viability. A serial hCG measurement to assess doubling times is needed for the diagnosis of threatened abortion or ectopic pregnancy. Abdominal ultrasonography allows visualization of a gestational sac around the time hCG levels reach 4000-6000 mIU/mL, whereas transvaginal ultrasonography can detect it at 1000-1500 mIU/mL, approximately 6 weeks from the last menstrual period. MSAFP is a marker for the detection of open neural tube defects and Down syndrome and would not be useful to explain the discrepancy between uterine size and dates.

7.
(C)
Low levels of hCG early in pregnancy can result from intrauterine or ectopic pregnancy. Serial hCG measurements in conjunction with clinical assessments are helpful to distinguish ectopic or failed pregnancies from normal ones. After the hCG level is 100 mIU/mL, the normal doubling time is 2.3 days in early pregnancy, 1.6 days from day 23 to 35, 2.0 days from day 35 to 42, and 3.4 from 41 to 50 days. To facilitate the calculations, it is helpful to remember that in weeks 5-8 of pregnancy, hCG levels increase by 29% in 24 hours, 66% in 48 hours, 114% in 72 hours, 175% in 96 hours, and 255% in 120 hours. Up to 15% of normal pregnancies may show a lag in doubling time, and up to 13% of ectopic pregnancies may present with physiologic increases in hCG levels.

8.
(C)
Ectopic pregnancy is the leading cause of maternal death during the first trimester. This condition is more common among women age 35-44 years. However, 15 to 24-year-old women have the highest mortality rate compared with other age groups. Predisposing factors include the use of an IUD, use of progestin-only pills, and tubal abnormalities secondary to a history of tubal surgery, PID, or previous ectopic pregnancy. Pelvic pain, amenorrhea followed by irregular vaginal bleeding, and the presence of an adnexal mass strongly suggest the possibility of an ectopic pregnancy. Rebound tenderness is present in up to 50% of cases.

9.
(E)
A pregnancy test is most important at this time to confirm the clinical suspicion of pregnancy. A wet mount prep and cervical swabs for gonorrhea and chlamydia are obtained during the pelvic examination to exclude STDs. A urinalysis and culture are needed to rule out UTI and/or glycosuria in this patient with abdominal pain, increased tiredness, frequent urination, and family history of diabetes. A CBC with differential leukocyte count, sedimentation rate, and CRP would be ordered if the physical examination reveals abdominal, adnexal, and/or cervical motion tenderness suggestive of PID. In pregnant girls, additional blood testing should include HIV, RPR, and Rh determinations. Serum amylase and lipase levels would be needed to rule out pancreatitis or cholangitis, which seem unlikely given the clinical presentation.

10.
(A)
The first step is to discuss the options available to her including

• Continuing pregnancy and becoming a parent

• Continuing pregnancy and giving the baby up for adoption

• Pregnancy termination

The patient’s feelings should be explored in the context of her present social situation, educational goals, financial status, and expectations about family support. She should be counseled about the potential effects of preexistent medical conditions, ongoing medication, smoking, alcohol, and other drugs on pregnancy outcomes. Counseling should be nonjudgmental and realistic but always supportive of the teen’s choice. Even though by virtue of her pregnancy the patient is now an emancipated minor, she should be encouraged to involve her family in the decision-making process. Legal requirements for parental notification vary from state to state, and health providers must be familiar with the laws applying to their specific geographic area to counsel their patients correctly.

The decision to involve the family is best made after an individualized assessment of the patient’s and family needs. Most teenagers need time to consider their options and it is helpful to arrange for a follow-up visit within a week with frequent telephone contact if needed. This is especially true for younger or emotionally immature adolescent girls. In this case, because she is already about 12 weeks pregnant, she needs to know that a decision has to be made in a matter of days rather than weeks. In the meantime, she should be referred to a case manager for further counseling. An appointment with an obstetrician should be arranged either for prenatal care or for pregnancy termination.

11.
(C)
Elective abortion is the most commonly performed surgical procedure in the United States. Of the almost 1 million teens who get pregnant every year, close to 50% carry pregnancy to term, 41% choose to have an abortion, and the rest end in miscarriages.

Teenagers are more likely to have a secondtrimester abortion than older women often because of failure to recognize the symptoms of pregnancy, ambivalence, fear of disclosure, and lack of awareness of available services. Morbidity and mortality from the procedure increase with gestational age and the risk doubles every 2 weeks after the eighth week. Suction curettage is the most widely used method (97% of cases) and may be performed up to a gestational age of 14 weeks. The procedure has a risk of death in 1:262,000 pregnancies when done before the eighth week and in 1:100,000 pregnancies in weeks 9-12. The comparable risk of death in carrying a pregnancy to term is 1:10,000. Dilation and evacuation (D&E) is used whenever abortion is performed between 13 and 16 weeks of pregnancy (in some places up to 20 weeks). The percentage of adolescents undergoing abortion in relation to the total number of abortions performed has declined significantly since the 1970s, and teens now account for about 20% of all abortions reported.